Spontaneous Pneumomediastinum and Bilateral Pneumothoraces in a Patient with Bleomycin-Induced Pneumonitis

Abstract

Bleomycin lung toxicity is well established and can manifest as bleomycin-induced pneumonitis, but pneumomediastinum and pneumothorax are very rare complications. We report the case of a 73-year-old woman, recently treated with bleomycin for Hodgkin's disease, who was admitted for bleomycin-induced pneumonitis. Two weeks later she had a pneumomediastinum with extensive subcutaneous emphysema and small bilateral pneumothoraces. Three months after that she was readmitted for dyspnoea. The CT scan showed complete regression of the pneumomediastinum but extensive bilateral ground-glass infiltrates. The patient died from respiratory failure 2 weeks later. LEARNING POINTS • Respiratory investigation before initiation of bleomycin treatment and then close follow-up during treatment of any abnormalitiesfound is mandatory, as bleomycin -induced toxicity can lead to fibrosis and secondary pneumothorax /pneumomediastinum with high morbidity/mortality. • Bleomycin-induce pneumonitis (BIP) is managed with bleomycin discontinuation (Grade 1A) and system corticosteroid (Grade 1B).• Supplemental oxygen is discouraged for BIP, but indicated for conservative management of pneumothoraces, so this case was managed with limited oxygen supplementation (aiming for oxygen saturation of 92-94%).KEYWORDS Bleomycin-induced pneumonitis, pneumomediastinum, pneumothorax CASE DESCRIPTION A 73-year-old woman who had never smoked and had been recently diagnosed with Hodgkin's lymphoma stage IIIB, was treated with two cycles of ABVD (adriamycin, bleomycin, vinblastine and dacarbazine) with a total dose of bleomycin of 200×10 3 units for 57 kg. The PET-CT scan after two cycles showed complete radiological and metabolic remission. However, a few days before the third cycle of chemotherapy, the patient developed rapidly progressive dyspnoea and a dry cough limiting her physical activity, together with mild hypoxaemia and bilateral lung crackles. A CT scan of the chest showed airspace consolidation, linear opacities, septal thickening especially at the bases, and traction bronchiectasis (Fig. 1). We diagnosed bleomycin-induced pneumonitis (BIP) because of the temporal relationship between the lung fibrosis and the treatment, and because of the absence of a differential diagnosis. We therefore stopped bleomycin and started systemic